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APPLICATION FCR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466,6781 ; PERMIT EXPIRES 1 YEAR FROM DATE ISSUED r - (Complete in Triplicate) . Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. -4 c r Job Address City o,'tot Size D VC1 - PM T - ._.. Owner's-Name it Address S� roar ��Z�t ��hone �� Contractor's Name �-License No. Phone TYPE OF WELL/PUMP: NEW WELL :,` WELL REPLACEMENT., _,.1,.,, DESTRUCTION ❑ PUMP IINSTALLATION'f7t%SYSTEIM-REPAIR ❑ -OTHER ❑ DISTANCE TO NEAREST: SEPTIC`TANK � SEWER LINES.. '^' DISPOSAL FLD. - PROP. LINE E _ __4-F -- FOUNDATION °" '~ AGRICULTURE WELL OTHER WELL } PITS/SUMPS INTENDED USE TYPE-OF WELL ;,,,,,PROBLEM AREA' ;CONSTRUCTION SPECIFICATIONS 7 ndustrial ❑ Open1Bottom 11Manteca 4 Dia'of Well Excavation ata. of Well Casing k 1omestic/Private Gravel-Pack _ ❑ Tracy Type of Casing- ��P °t Specifications I ❑ Public -❑ Other El Delta't _k,._Depth of Grout Seal Ty a of Grout ❑ IrrigationApprox. De th Eastern tSurf� Seal Installed by f .� 1- ` .- - °". tats- uric Done . Repair Work bone ❑ Type•of Pumpp :'�H�P_.:�—.,� �- - -= S f Well Destruction Well Diame r -k2 — Sealing'Material (top 501 ' Depth Y1 Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION El--REPAIR/ADDITION ❑ DESTRUCTION'❑ Wo septic system permitted if public sewer is t f "available-within 200 feet.) "—�- Installation will serve::b.Residence_— -Commercial : Other Y r Number of living units: Number of bedrooms Character of soil to a depth=iif 3"feet: "'" "` ^." Water table depth SEPTIC TANK ❑ `Type/Mfg i Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal -Distance to nearest: Well -Foundation Property Line � 1 LEACHING LINE ❑' o. & Length of lines Total length/size �: ` FILTER BED ❑ Distance to nearest: Well Foundation Property Line � f SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well - Foundation Property Line DISPOSAL PONDS ❑ � I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and-regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractors hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of California." The ap us all for all requ' inspect s. Camp drawing on reverse side. Signed X Title: Date: '. DEPARTMENT USE ONLY 41 Application Accepted by Date �I Area Q ! 1 / Pit or Grout Inspection by Date [ Final nspection by Data Additional Comments: ` 0 � �/ 09�Stk 466-6761 ❑ Lodi 369-3621 ❑ Manteca 823-7104 El Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazeltan Ave., P.O. Box 2009, Stk., CA 55201 k FEEAMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMET`�'NO. 1 INFO r ♦• + EH1324(REV.10189) EH 1426